Basics of percutaneous coronary intervention

1. Basics of Percutaneous
Coronary Intervention
Dr Waseem A Siddiqui, MD,
MBBS

2. EPIDEMIOLOGY CORONARY HEART DISEASE (CHD)
 Major causes of morbidity and mortality all over the world
 In 2016, American Heart Association (AHA) reported that 15.5 million persons > 20 years of age in USA
have CHD, & prevalence increases with age
 Every 42 seconds, an American suffers from MI1
 CHD mortality declined over the last decades in western countries, it is expected to continue increasing
in developing countries2
 Age-standardized CVD death rate is 272/ 100 000 population in India, which is higher than global
average of 235 per 100 000 population.2
 Current estimates from epidemiologic studies show prevalence of CHD 7-13% in urban and 2-7% in
rural area.3
1. https://www.ncbi.nlm.nih.gov/pubmed/22929818
2. https://www.ncbi.nlm.nih.gov/pubmed/?term=cardiovascular+disease+in+India.+Current+Epidemiology+and+Future+directions
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860846

3. TREATMENT MODALITIES
Lifestyle Modification & Risk factor Management : Smoking , Exercise,
Weight Control, Management of DM, HTN and Hyperlipidaemia
Pharmacological therapy :
Antiplatelet and antianginal drugs
Surgical Management (Revascularization):
Percutaneous Coronary Intervention(PCI)
Coronary Artery Bypass Grafting (CABG)
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/coronary-artery-disease

4. PERCUTANEOUS CORONARY INTERVENTIONS
 Percutaneous coronary interventions (PCI) include
percutaneous transluminal coronary angioplasty
(PTCA) with or without stent insertion
 First performed in human by Andreas Gruentzig in
1971
 Most commonly performed interventional procedure
 PTCA and stent placement within 90 min of onset of
pain is the optimal treatment of transmural ST-
segment–elevation myocardial infarction (STEMI).
 Elective PCI may be appropriate for post-MI patients
who have recurrent or inducible angina before
hospital discharge and for patients who have angina
and remain symptomatic despite medical treatment.
Michael J. Shea. Percutaneous Coronary Interventions. MSDManual. Feb, 2016

5. INDICATIONS
 Acute ST-elevation
myocardial infarction
(STEMI)
 Non–ST-elevation
acute coronary
syndrome (NSTE-
ACS)
 Unstable angina
 Stable angina
 Anginal equivalent (eg,
dyspnea, arrhythmia,
or dizziness or
syncope)
 High risk stress test
findings
CONTRAINDICATION
S
• Coagulopathy
• Decompensated
congestive heart
failure
• Uncontrolled
Hypertension
• Pregnancy
• Inability for patient
cooperation
• Active infection
• Renal Failure
• Contrast mediumGeorge A Stouffer, at al. Percutaneous Coronary Intervention (PCI). Drug and disease,

6. TYPES OF PCI IN ACS WITH
STEMI
 Primary PCI: Procedure is
performed within 12 hours
after the onset of symptoms.
 Rescue PCI: Rescue PCI is
recommended if thrombolysis
failed within 45-60 min after
starting the administration
 Post thrombolysis PCI:
Thrombolysis-facilitated
primary PCI
 Ischaemia guided PCI:
Ischaemia-driven PCI after
thrombolysis
Ali Ghanie. Indication for Percutaneous Coronary Angioplasty. Acta Med Indones-Indones J Intern
Med. 2009; 41: 159-65

7. EQUIPMENTS
Balloon catheters for PCI have the following features:
 A steerable guide wire precedes balloon into artery & permits navigation
through coronary tree
 Inflation of balloon compresses & axially redistributes atheromatous plaque & stretches
vessel wall
 Balloon catheter also serves as adjunctive device for many other interventional therapies
Intracoronary stents have the following features:
 Stents differ with respect to composition, design, delivery system & drug delivered
 Drug-eluting stents (DESs) have demonstrated significant reductions in re-stenosis &
target-lesion revascularization rates, with further reduction with second-generation DESs
 In the United States, commercially available DESs are second-generation models that
elute everolimus & zotarolimus
 Both stents with bio-absorbable polymer & fully bioresorbable scaffolds
 Stents are conventionally placed after balloon predilation, but in selected
coronary lesions, direct stenting may lead to better outcomes
George A Stouffer, at al. Percutaneous Coronary Intervention (PCI). Drug and disease, Oct. 16.

8. PROCEDURE
 PCI is done via percutaneous femoral,
radial, or brachial artery puncture.
 Radial approach is technically
demanding compared to the femoral
approach but may reduce patient
discomfort, improve time to ambulation,
and reduce the incidence of some
complications (eg, bleeding,
pseudoaneurysm formation).
 A guiding catheter is inserted into a
large peripheral artery and threaded to
appropriate coronary ostium.
 A balloon-tipped catheter, guided by
fluoroscopy or intravascular
ultrasonography, is aligned within the
stenosis, then inflated to disrupt the
atherosclerotic plaque and dilate the
artery.
 Angiography is repeated after the
procedure to document any changes.
 The procedure is commonly done in 2 or
3 vessels as needed.
Michael J. Shea. Percutaneous Coronary Interventions. MSDManual. Feb,
2016

9. ANTICOAGULATION & ANCILLARY THERAPY
Antithrombotic therapy:
 Aspirin (162-325 mg) F/B Unfractionated heparin (UFH), low-molecular-weight
heparin (LMWH), or bivalirudin used at the time of balloon angioplasty or PCI.
Antiplatelet therapy
 Thienopyridines (clopidogrel, prasugrel, ticagrelor) and glycoprotein IIb/IIIa
inhibitors (abciximab, eptifibatide, tirofiban) are the standard of care for patients
with unstable non-ST-segment elevation myocardial infarction for at least 9 to 12
months after PCI.
Glycoprotein inhibitor therapy
 Abciximab, tirofiban, and eptifibatide reduce ischemic complications in patients
undergoing balloon angioplasty and coronary stenting.
 Calcium channel blockers and nitrates may also reduce risk of coronary spasm.
Michael J. Shea. Percutaneous Coronary Interventions. MSDManual. Feb, 2016

10. STENT TYPES
• Latest type of coronary stent
• Contains a drug with active healing technology(helps in
healing process of artery)
• Has coating both sides
DUAL THERAPY STENT
• Drug eluting stent with a dissolvable type of scaffold –
absorbed overtime
• Coated with drug released from polymer
• Reduces the chances of restenosis
BIORESORBABLE
VASCULAR SCAFFOLD
• Antibody coated stent
• Does not contain a polymer or drug
• Speeds up the epithelialization of the artery—promoted
natural healing
BIO-ENGINEERED
STENT
DRUG ELUTING STENT
BARE METAL STENT
https://www.orbusneich.com/en/patient/types-coronary-stents-0
• Stainless steel, without special coating
• As artery heals, tissue grows around stent holding it in place
• Overgrowth of scar tissue-↑ risk of re-blockage
• Coated with medications that help to prevent the growth of
scar tissue in the artery lining
• ↑ chances of blood clots– stent thrombosis

11. COMPICATIONS
MAJOR
• Allergic & Adverse reaction (30%)
• Acute MI requiring emergency
CABG (5-30%)
• Distal embolization (<2%)
• Nephropathy (3.3-16.5%)
• Hematoma and Retroperitoneal
Hemorrhage (2.8%)
• Pseudoaneurysm (0.5-2.0%)
• Arterio-venous Fistula (1%)
• Ventricular arrhythmia (1.3-3.5%)
MINOR
• Cerebrovascular Complications
(0.07-0.23%)
• Abrupt closure and dissections
(0.42% )
• Radiation injury
• Hypotension
• Hypoglycemia
• Death (0.08-1%)
• Infection (<1%)
Morteza Tavakol, et al. Risks and Complications of Coronary Angiography: A Comprehensive Review. Glob J Health Sci. 2012 Jan; 4(1): 65–93
Major complications from PIC occur in <2% of the population,
with mortality of <0.08%

12. THANK YOU